Category Archives: Most Wanted List

NTSB Video Series Highlights Safety Benefits of Connected-Vehicle Technology, Raises Concern about Future of V2X

By Member Michael Graham

Today, the NTSB released a four-part video series: “V2X: Preserving the Future of Connected-Vehicle Technology.” Vehicle-to-everything (V2X) is one of the most promising life-saving technologies available today. While radars and sensors are limited to line-of-sight and are often impeded by inclement weather, V2X technology uses direct communication between vehicles and with infrastructure. Additionally, V2X technology increases the safety and visibility of vulnerable road users by alerting drivers to the presence of pedestrians, bicyclists, and motorcyclists that may be outside a driver’s or vehicle‑based sensor’s field of observation.

Despite the immense safety potential of V2X, the Federal Communications Commission’s (FCC’s) recent actions threaten its basic viability. In May 2021, the FCC finalized the rulemaking to substantially reduce the available spectrum for V2X applications by 60 percent. This ruling retained only 30 MHz for transportation safety applications and invited interference from the surrounding bands from unlicensed Wi-Fi devices. Research by the US Department of Transportation (DOT) demonstrated that expected interference into the spectrum would further compromise the integrity of safety applications—rendering V2X untenable.

In this video series, I had the privilege of interviewing eight experts from government, industry, academia, and associations about the safety benefits and the maturity level of V2X technology, the reasons for its scarce deployment, and the impact of the FCC’s recent actions to limit the spectrum available for transportation safety.

I talked with some of the leading voices in the V2X space, including:

  • Debby Bezzina, Center for Connected and Automated Transportation, University of Michigan Transportation Research Institute
  • Bob Kreeb, National Highway Traffic Safety Administration
  • Ken Leonard, US Department of Transportation’s Intelligent Transportation Systems (ITS) Joint Program Office
  • Laura Chace, ITS America
  • Scott Marler, American Association of State Highway and Transportation Officials
  • John Hibbard, Georgia Department of Transportation
  • John Capp, General Motors
  • John Kenney, Toyota

The NTSB first issued a safety recommendation to the FCC to allocate spectrum for V2X technology in 1995, and we continue to fervently believe in the promise of V2X technology to save lives.

This series was developed as part of the NTSB’s Most Wanted List safety topic, Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles. I sincerely appreciate each of the eight guests who graciously agreed to participate in the series.

I encourage you to watch all four episodes of this series on the NTSB YouTube channel. You can learn more about the video series, including our featured guests and supporting research, on the NTSB’s V2X web page.

A New Year’s Resolution We All Can Make: Prioritize Safety

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

As 2021 ends, it’s time to reflect on the past 12 months and begin to set goals for the year ahead. After all, as Zig Ziglar once said, “if you aim at nothing, you will hit it every time.” So, let us all aim to improve the safety of our transportation system in 2022.

The NTSB recognizes the need for improvements in all modes of transportation–on the roads, rails, waterways, pipelines, and in the sky. Our 2021–2022 NTSB Most Wanted List of Transportation Safety Improvements (MWL), released in April this year, highlights the transportation safety improvements we believe are needed now to prevent accidents and crashes, reduce injuries, and save lives. We use the list to focus our advocacy efforts and to serve as an important call to action. We ask lawmakers, industry, advocacy, community organizations, and the traveling public to act and champion safety.

As a fellow safety advocate, I ask you to join me in a New Year’s resolution: I pledge to do my part to make transportation safer for all.

To help you take steps to accomplish this resolution, our MWL outlines actions you can take to make transportation safer:

  1. Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations
  1. Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs
  1. Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes
  1. Protect Vulnerable Road Users through a Safe System Approach 
  1. Prevent Alcohol- and Other Drug-Impaired Driving
  1. Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles
  1. Eliminate Distracted Driving
  1. Improve Passenger and Fishing Vessel Safety
  1. Improve Pipeline Leak Detection and Mitigation
  1. Improve Rail Worker Safety

Achieving these improvements is possible; otherwise, they wouldn’t be on our list. The NTSB MWL includes tangible changes and solutions that will, undoubtedly, save lives. But it’s only words on a list if no action is taken. Unlike Times Square on New Year’s Eve, we cannot drop the ball on improvements to transportation safety. The clock is ticking, and the countdown has begun—we can’t afford to waste any more time. Make the resolution to do your part to make transportation safer for all!

In closing, I’d like to thank the transportation safety stakeholders, industry, lawmakers, and advocates we have worked with in 2021 and we look forward to working together in 2022 and beyond.

Drive Sober and Save Lives the Holiday Season

By Member Tom Chapman

Unlike last year when many holiday gatherings were cancelled due to the pandemic, many of us will return to visiting family and attending holiday parties this year. Some may see this as an opportunity for a 2020 do-over and may overindulge on merriment.

The holiday season is a time of increased impaired-driving crashes due to these celebrations and gatherings. The President has designated December as National Impaired Driving Prevention Month, and it serves as a reminder that traffic fatalities and injuries attributed to impaired driving are 100 percent preventable.

In 2019, according to the National Highway Traffic Safety Administration (NHTSA), 10,142 people were killed in traffic crashes in which at least one driver had a blood alcohol concentration (BAC) level of 0.08 g/dL or higher. That number comprises 28 percent of the 36,096 traffic fatalities that year.  Also of concern, NHTSA estimated a 9 percent increase in police-reported alcohol involved crashes between 2019 and 2020.  These deaths are not abstract statistics. These were mothers and fathers, husbands and wives, children, friends, and other loved ones. They are people who will be deeply missed at this year’s holiday gatherings.

In addition to alcohol, there are other impairing substances, such as marijuana, other illegal drugs, and prescribed and over-the-counter medications. These can all be as dangerous as alcohol for a driver. As we continue to understand more about the extent to which drugged driving contributes to fatalities and injuries, we are certain that the prevalence of this, as well as multiple or “poly-drug” use while driving, is on the rise.

In June, NHTSA published an update on research looking at drug and alcohol prevalence in seriously and fatally injured road users before and during the COVID-19 public health emergency. The overall picture is very troubling. In general, drug and alcohol prevalence among drivers seriously injured or killed in crashes increased during the pandemic. Significant increases were reported for drivers testing positive for cannabinoids and multiple substances. These are not the trends that we want to see.

The NTSB has issued specific recommendations that, if implemented, would help prevent these deaths and injuries. They include required all-offender ignition interlocks, .05 (or lower) BAC limits, and a national drug testing standard. Our 2021-2022 Most Wanted List of Transportation Safety Improvements includes the safety item “Prevent Alcohol- and other Drug-impaired Driving,” with these and several additional safety recommendations remaining open.

Congress recently passed the Infrastructure Investment and Jobs Act, which advances some of NTSB’s most important safety recommendations. For example, the new law requires the Secretary of Transportation to issue a final rule requiring all new passenger motor vehicles to be equipped with advanced drunk driving prevention technology within three years. I am encouraged and hopeful we’ll see this technology incorporated soon, as it could be a game-changer for alcohol-impaired driving.

By exercising personal responsibility, you can do your part to prevent impaired driving crashes during the holiday season. It’s simple. Choose drinking or driving, but not both. Have a designated driver. Call a taxi or ride-share service. These basic steps will save lives. Let’s ensure there will be many more enjoyable holiday seasons to come.

Three Key Strategies to Prevent Teen Distracted-Driving Crashes

By Bryan Delaney, NTSB Safety Advocate

Motor vehicle crashes are a leading cause of death for teens and, for today’s teens, distraction is a major factor in crash risk. According to the National Highway Traffic Safety Administration (NHTSA), dialing a phone number while operating a vehicle increases a teen’s risk of crash by 6 times, and texting while driving increases crash risk by 23 times.

The NTSB recognizes the importance of teen driver safety, and we’ve made numerous recommendations to prevent distracted driving and promote safe driving behaviors for these vulnerable road users. The following strategies can improve teen driver safety and reduce the risk of teen distracted-driving crashes.

Educate Teens on the Risk of Distracted Driving

Education is key to changing driving behaviors among teens. Parents should model safe driving behaviors, laying out expectations and enforcing consequences if rules are broken. Adults must remember that the driving habits they teach teens through formal education and informal instruction is only half the battle—they must also “walk the walk” by avoiding risky behaviors and teaching by example.

Teens must also set a positive example for their peers by buckling up; obeying the speed limit; avoiding distracted, drowsy, and impaired driving; and making sure their emergency information is up to date and accessible in case of a crash. Peer-to-peer education and accountability can foster a driving environment where distracted driving is unacceptable.

Ban Portable Electronic Devices While Driving

States have a role in preventing teen distracted driving. For a decade, the NTSB has recommended that states prohibit the nonemergency use of all portable electronic devices, except those designed to aid the driving task, while driving. We need a cultural shift to put human life at the center of our transportation system over perceived productivity or social engagement. Driving distracted must become as unacceptable as driving impaired by alcohol or other drugs—for both adult and teen drivers.

Establish a Comprehensive Graduated Driver License Law

All states have some form of a graduated driver license (GDL) program, but no state has a comprehensive program with all provisions to minimize driving risks for teens. As outlined below, the NTSB recommends that all states establish a comprehensive, three-phase GDL law for teen drivers to gain driving experience before obtaining a full license. The following GDL provisions can help states improve overall teen driving and reduce crashes resulting from inexperience.

  • Phase 1: Learner’s permit
    • 6-month minimum holding period (without an at-fault driver or traffic violation)
    • Supervised driver requirement with supervising driver age 21 or older
    • Seat belts used by all occupants in all seating positions
    • Driving with a measurable blood alcohol level prohibited
    • Cell phone use prohibited while driving
  • Phase 2: Intermediate (provisional) license
    • 6-month minimum holding period (without an at-fault crash or traffic violation)
    • Nighttime driving restriction
    • Teen passenger restriction (up to 1 passenger)
    • Seat belts used by all occupants in all seating positions
    • Driving with a measurable blood alcohol level prohibited
    • Cell phone use prohibited while driving
  • Phase 3: Full licensure
    • Seat belts used by all occupants in all seating positions
    • Driving with a measurable blood alcohol level by all drivers under age 21 prohibited

Distraction is impairing. Even cognitive distraction slows your reaction time, and visual and manual distraction might make it impossible to see or avoid a hazard. All drivers—but especially teens, among whom distraction is pervasive—should keep their eyes on the road, their hands on the wheel, and their phones in the glovebox.

No text, email, or notification is worth a life.

Paying Passengers Deserve Safety on All Flights

By Member Michael Graham

In 2015, the Federal Aviation Administration (FAA) required commercial airlines to develop a comprehensive safety management system (SMS) to improve safety for the flying public. An SMS is an organization-wide system that ensures operators are properly identifying, assessing, and mitigating the conditions that exist for an accident to occur.

The FAA, however, has not required the same for revenue passenger-carrying operations under Title 14 Code of Federal Regulations Parts 91 and 135, leaving passengers on these flights at unnecessary risk. Similar to passengers of commercial airlines, those passengers who pay for a charter flight, skydiving experience, or hot air balloon ride exercise no control and bear no responsibility over the airworthiness or operation of which they are being flown. Therefore, paying passengers of Part 91 and Part 135 flights deserve a similar level of safety as those who fly on a commercial airline. That is why Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations is on the NTSB’s 2021–2022 Most Wanted List of Transportation Safety Improvements.

The Problem

Togiak, AK – Separated section of empennage with vertical and horizontal stabilizers and rudder attached.

Since the airlines were required to develop an SMS in 2015, the NTSB continues to investigate Part 91 and Part 135 accidents that could have been prevented by an effective SMS—all involving paying passengers—including the following:

  • On October 2, 2016, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane operated under Part 135, collided with steep, mountainous terrain northwest of Togiak Airport in Alaska, killing both commercial pilots and their passenger. The operator did not have an SMS, and we found that after experiencing two previous controlled flight into terrain (CFIT) accidents in the preceding three years the company had missed opportunities to adequately assess this CFIT-related risks and implement more effective strategies for preventing such accidents.
  • On May 15, 2017, a Learjet 35A departed controlled flight while on a circling approach to runway 1 at Teterboro Airport in New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command (SIC) died. The operator lacked both an SMS and a flight data monitoring program, and the company did not identify or mitigate hazards that contributed to this accident, including the pairing of pilots who had exhibited difficulties in training, the informal practice of some captains who allowed unapproved copilots to serve as pilot flying, and other patterns of flight crew procedural noncompliance.
  • On March 11, 2018, an Airbus Helicopters AS350 B2 lost engine power during an aerial photography flight and ditched on the East River in New York City. The pilot sustained minor injuries and his five passengers drowned. Again, the operator lacked an SMS and, although the operator’s employees were aware of the potential hazards that led to the accident, the operator did not have a robust safety program that could adequately prioritize and address hazards that played a role in this accident, including the potential for entanglement of a passenger harness/tether system with floor-mounted engine controls, the inability of passengers to evacuate without assistance, and the possibility the emergency flotation system might only partially inflate due to difficulties with the float activation mechanism.
  • On June 21, 2019, a Beech King Air 65-A90 airplane, N256TA, impacted terrain after takeoff from Dillingham Airfield, Mokuleia, Hawaii. The pilot and 10 passengers were fatally injured, and the airplane was destroyed by impact forces and a postcrash fire. In this accident, the operator failed to address numerous safety issues that a formal SMS would likely have identified as significant risks and prevented the accident. These included allowing passengers to be transported in a poorly maintained airplane, not implementing any standard operating procedures (SOPs) or written guidance for the company’s parachute operations, providing no structured initial or recurrent training for company pilots, using flawed methods in calculating the weight and balance of its flights, and allowing its pilot to routinely violate numerous Federal Aviation Regulations. In April 2021, the NTSB issued Safety Recommendation A-21-13, which asked the FAA to require SMS for the revenue passenger-carrying operations discussed in the Part 91 aviation investigation report; these operations included parachute jump flights.

These accidents seemingly had little in common, yet, in each case, an effective SMS might have helped the operator identify hazards or better mitigate those that were already known.

An Effective SMS

Any operator can print out the four pillars of an SMS, put up a poster, and add an anonymous comment box to the breakroom. However, implementing an effective SMS that changes safety behavior in an organization is not a box-checking exercise. An effective SMS is a management system that brings safety conscious behaviors to the forefront of an organization, which aids in identifying and mitigating risks inherent in flight operations and other activities. Every day, every task.

An effective SMS must fully address the following four pillars:

  • Safety policy
    • Sets objectives, assigns responsibilities, and develops standards
    • Clearly defines roles and responsibilities
    • Engages accountable executive
  • Safety risk management
    • Systematic processes for identifying hazards and mitigating risks
  • Safety assurance
    • Monitors, measures, audits, and assesses the performance of SMS
  • Safety promotion
    • Ensures a positive and just safety culture
    • Circulates and incorporates safety lessons
    • Advocates, communicates, and trains the principles of SMS

By establishing an effective SMS and creating a safety culture that fosters the free flow of safety-related information and organizational learning about the nature of operational risks, operators will reduce the likelihood of an accident and improve the safety of their flight operations.

What Can Be Done

Oversight is necessary to ensure operators adhere to the principles and processes of an effective SMS to provide sufficient safety to paying passengers. The NTSB has investigated numerous accidents involving operators whose deficient SMS failed to identify and mitigate the conditions that contributed to the accident. Therefore, the NTSB calls on the FAA to require SMS for all revenue passenger-carrying Part 91 and Part 135 operations and provide ongoing oversight.

To operators, the NTSB’s investigations repeatedly demonstrate that an effective SMS could have identified the hazards and mitigated the risks that led to the accidents. Do not wait for an accident to occur or a FAA mandate to invest in the safety of your passengers, pilots, and other personnel, voluntarily implement an effective SMS today.